T h e La p a ro s c o p i c Management of Endometriosis in Patients with Pelvic Pain Patrick Yeung Jr,
MD
KEYWORDS Endometriosis Excision surgery Laser surgery Diagnostic imaging Pelvic pain Recurrence KEY POINTS Diagnostic laparoscopy is indicated for women whose quality of life is significantly affected, for whom hormonal suppression has failed (or is contraindicated), or who desire fertility. Transvaginal ultrasonographic imaging (which may include evaluation for deep endometriosis) can aid in surgical planning. Optimal excision or removal of disease is the best way to reduce recurrence rates, and may also be a way to conserve normal ovaries and avoid surgical menopause, even when hysterectomy or definitive therapy is indicated. Early diagnosis and treatment may be the best way to prevent the development of extensive disease and, perhaps, to preserve fertility.
Video of ureterolysis accompanies this article at http:// www.obgyn.theclinics.com/ INTRODUCTION
Endometriosis is estimated to be present in 1 of every 10 women.1,2 It is a condition whereby endometrial glands and stroma (normally found within the endometrial cavity and shed during the menstrual period) are found outside the uterine cavity. Endometriosis is an underdiagnosed and undertreated problem, and multiple studies have shown that it can take an average of up to 12 years to diagnose (especially in teenagers) from the time of onset of symptoms to the diagnosis at laparoscopy.3–6 This delay in diagnosis can contribute to impaired quality of life and may have implications for fertility.7–9 Center for Endometriosis, Division of Minimally Invasive Gynecologic Surgery, Department of Obstetrics, Gynecology & Women’s Health, Saint Louis University, 6420 Clayton Road, Suite 290, St Louis, MO 63117, USA E-mail address: [email protected] Obstet Gynecol Clin N Am 41 (2014) 371–383 http://dx.doi.org/10.1016/j.ogc.2014.05.002 obgyn.theclinics.com 0889-8545/14/$ – see front matter Ó 2014 Elsevier Inc. All rights reserved.
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Laparoscopy is the gold standard for the diagnosis of endometriosis, by visualization of implants characteristic of endometriosis or, better still, by histology of excised lesions.10 Laparoscopy is also the preferred route for treatment (when possible) of endometriosis because laparoscopy affords the benefits of magnification, illumination, and high-definition optics to better visualize the disease. Although there is no cure for endometriosis, optimal laparoscopic management can benefit patients with pain (and improve fertility) and improve their quality of life.11–13 Patients with endometriosis might benefit from early diagnosis and laparoscopic management, before progression of the disease, and providers should know when to operate and when to refer these patients.8 ENDOMETRIOSIS AND PAIN
Endometriosis is known to be associated with pain, and should be thought of as part of a comprehensive evaluation for pain.9 During the adolescent period at least 75% of patients who failed medical treatment were found to have endometriosis.7 Some algorithms recommend a diagnostic laparoscopy later in the evaluation after all other causes of pain have been ruled out or treated, including interstitial cystitis, vaginismus or myofascial pain, and pudendal neuralgia. Others recommend diagnostic laparoscopy sooner because endometriosis, unlike other causes of pain, can affect fertility, and surgical management for endometriosis may improve or preserve fertility.9,14 Although it is known that endometriosis and pain are associated, the exact causal relationship is not clear. Of note, the extent of disease (based on the most widely used revised American Society of Reproductive Medicine [r-ASRM] classification system15) does not correlate well with the severity of symptoms.16 The way that endometriosis is currently classified is based on extent of disease, the presence of endometriomas, and adnexal or cul-de-sac adhesions. Deep endometriosis (or deep infiltrating endometriosis [DIE]) is not a part of the current classification system. However, there is evidence to show that the location of deep endometriosis has some correlation to the location of pain,17 whereas the location of superficial endometriosis does not.18 Newer classification systems are being developed to include DIE.19 HORMONAL VERSUS SURGICAL MANAGEMENT
Hormonal suppression is often recommended as first-line treatment for pain thought to arise from endometriosis.10 Hormonal suppression can improve symptoms such as pelvic pain and dysmenorrhea. Empiric therapy with hormonal suppression, including a gonodotropin-releasing hormone agonist (GnRHa) or birth control pills, is often used to control symptoms, as a form of diagnostic trial, and to prevent progression of disease. However, a response to empiric therapy (meaning improvement in symptoms), for example, with a GnRHa, is not diagnostic for the presence of endometriosis.10 Failure of pain to respond adequately to hormonal suppression should be investigated further for endometriosis. Hormone suppression may do little to prevent recurrence or progression of the actual disease. A study of 90 patients by Doyle and colleagues20 in 2009 showed that hormonal suppression given after surgery worsened (10%) or did not change staging or extent of the disease (70%) in 4 of every 5 women. Moreover, studies have shown that the need for hormonal suppression to control pain in earlier years may be a marker for more advanced disease. Studies by Chapron and colleagues21–23 in 2011 showed that patients with severe endometriosis, when questioned about their adolescent history, had greater school absenteeism and an earlier or extended need for hormonal suppression to control pain in the adolescent years.
Endometriosis in Patients with Pelvic Pain
Finally, hormonal suppression does not improve fertility, neither while the patient is on suppression nor in the future.24,25 DIAGNOSIS History and Evaluation
Symptoms characteristic of endometriosis include the following: dysmenorrhea, chronic pelvic pain (more than 3 months of pelvic pain outside the menstrual period, between the umbilicus and the thighs), deep dyspareunia, period-related dyschezia, and period-related dysuria.10 Chronic pelvic pain has many different potential causes and is often multifactorial. Causes of chronic pelvic pain include endometriosis, pelvic inflammatory disease, interstitial cystitis, urinary tract infection, myofascial pain or vaginismus, and irritable bowel syndrome, to name a few.26 A thorough evaluation and testing of the causes of chronic pain should be performed as directed by the history. Moreover, chronic pelvic pain can lead to centralization or sensitization to pain, which may need to be addressed. Under such circumstances the brain is sensitized to feeling pain even when the source of pain is treated or diminished.27 A multimodal team approach is often the best way to treat chronic pelvic pain. Within the evaluation for chronic pelvic pain, endometriosis should be especially addressed if fertility or future fertility is desired.28 Indications for Laparoscopy
Providers who care for women should have a high index of suspicion for endometriosis when symptoms affect activities of daily living or quality of life. Examples include pelvic pain or dysmenorrhea that leads to absenteeism from school or work, deep dyspareunia that prohibits intercourse, or the need for narcotics to deal with pelvic pain.12 In the adolescent population in particular, patients who have chronic pelvic pain but whose symptoms fail to improve with hormonal suppression have a very high prevalence of endometriosis. Experts have recommended that expectant management is inappropriate in patients with a visual analog scale score of greater than 7 or in patients with a poor quality of life as subjectively assessed by the patient.29 Infertility is another reason to perform laparoscopy for endometriosis. Historically, all patients with infertility have received a routine laparoscopy for evaluation of endometriosis given the known association of endometriosis with infertility. Current recommendations for laparoscopy because of fertility concerns include: age younger than 30 years; when in vitro fertilization (IVF) is not an option; or when a patient has failed 2 attempts at IVF.28 The laparoscopic management of endometriosis has been shown to improve both pain30 and fertility outcomes.13,31 In a recent study by Lee and colleagues,32 42% of patients (with endometriosis ranging from stages I to IV) conceived successfully without hormonal treatment or artificial reproductive technologies within a year after surgery. In another study by Darai and colleagues33 in 2005, pregnancy rates for a cohort of 34 women requiring colorectal bowel resection for advanced disease was 45% within 24 months. The Potential Benefit of Early Diagnosis and Treatment of Endometriosis
Endometriosis is thought to be a progressive disease, although not in all cases.8,34 Thus extensive or deep disease can arise from superficial disease. Some have touted the benefits of diagnosing and treating endometriosis earlier in the disease process, even in adolescence, which could improve lifelong pain and quality of life, and reduce the rate of progression to more advanced disease.13 Early intervention and optimal removal of disease, by reducing the rate of recurrence or progression, has the
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potential to improve or preserve downstream fertility,12 although this has to be systematically studied. Preoperative Examination
The goal of surgery should be to “see and treat” laparoscopy when possible.35 That is, at laparoscopy the disease is fully identified and optimally treated at the same time. The best way to achieve this is with thorough preoperative planning that includes history, physical examination, and preoperative imaging, usually transvaginal ultrasonography (TVUS). A physical examination should include assessment of the uterosacral ligaments (thickening, shortening, nodularity), mobility of the uterus and adnexa, adnexal masses, and a rectovaginal examination for cul-de-sac nodularity. Deep disease may be able to be diagnosed or suspected preoperatively, and ideally managed at surgery in a multidisciplinary fashion if necessary.36 A history of dyschezia may increase suspicion for deep disease. A fixed or immobile uterus, or cul-de-sac nodularity, would imply an obliterated cul-de-sac or deep endometriosis. Preoperative Imaging
TVUS is the imaging modality of choice for the assessment of suspected endometriomas or deep endometriosis. TVUS is an excellent imaging modality for female reproductive organs, and can be performed in the gynecologist office setting, although it is fairly operator-dependent.10 With proper training and experience in specialized centers, TVUS with bowel preparation (TVUS-BP), whereby the distal bowel has been emptied by an enema, has been shown to be as accurate as pelvic magnetic resonance imaging in diagnosing deep endometriosis in the posterior cul-de-sac.37–40 Preoperative ultrasonography may indicate deep disease directly, or indirectly if an endometrioma larger than 8 cm or bilateral endometriomas are suspected.41,42 In 2010 Goncalves and colleagues,37 in a study involving 194 patients, showed the ability of TVUS-BP to predict the number of lesions in cases of deep endometriosis with a sensitivity and specificity of 97% and 100%, respectively (for a single bowel nodule), and with a positive predictive value (PPV) and negative predictive value (NPV) of 100% and 98%, respectively. Regarding the diagnosis of infiltration of the submucosal/ mucosal layer, TVUS-BP had a sensitivity of 83%, specificity 94%, PPV 77%, and NPV 96%. Clearly this type of accurate imaging would be invaluable in helping to define the surgical strategy. If the surgeon or center is not able to manage deep endometriosis suspected before surgery or discovered at the time of surgery, the patient should be referred to a surgeon or center that is able to manage deep or extensive endometriosis.13,43 SURGICAL TECHNIQUES
The goals of laparoscopic surgery for endometriosis are: optimal removal or treatment of all visible and deep disease; restoration and preservation of anatomy and function; and adhesion prevention.29 Pelvic pain and fertility can be improved with surgical intervention.30,31 Near-Contact Laparoscopy
For early or mild forms of endometriosis (r-ASRM Stage 1–2), optimal excision depends first on recognizing endometriosis in all of its forms.11 The most common way to diagnose endometriosis is to visualize typical implants that have a “powderburn” appearance. However, a histologic diagnosis is more accurate, especially when the lesions have a more atypical or subtle appearance. Atypical lesions include
Endometriosis in Patients with Pelvic Pain
“red flame” lesions, white fibrotic lesions, vesicular or miliary lesions, and retraction pockets (sometimes called Allen-Masterson pockets) (Figs. 1 and 2).44 Careful and systematic near-contact laparoscopy should be used to find all lesions suspicious for endometriosis (Fig. 3).44 Removal of Deep Disease
For more advanced (or deep) endometriosis (r-ASRM Stage 2–4), optimal excision depends on not just recognition of peritoneal or superficial disease, but on recognition of deep disease and restoration of anatomy.45 Surgery in these cases often includes bilateral ureterolysis, cystectomy, adhesiolysis, and enterolysis, and opening of an obliterated cul-de-sac or “frozen” pelvis. Of note, adhesions distort not just anatomy but also visualization of endometriosis, so adhesiolysis alone is insufficient to achieve an optimal surgical result. Once adhesions have been reduced, excision of the peritoneum or deep disease must occur for proper treatment of endometriosis (Fig. 4). It has been suggested that surgery for ovarian endometriosis alone is insufficient treatment.42,46 Evidence shows that treatment of deep endometriosis, including bowel endometriosis and ovarian endometriomas, has been shown to benefit both pain and pregnancy outcomes,13 with low recurrence rates.47,48 Some have recommended that centers of excellence be created to manage difficult or challenging cases of endometriosis.49 Excision Versus Ablation
There is an ongoing debate about the best surgical method to treat endometriosis. Published comparative studies50,51 do not account for surgical experience, nor of the presence of deep endometriosis. There are several surgical scenarios in which excision (removing the disease whereby a specimen is produced and sent to histology) is intuitively superior to ablation (destruction of the disease with energy without a specimen being produced). Such situations would include: deep endometriosis (whereby ablation would just treat the “tip of the iceberg”); ovarian endometriomas (which can be thought of as a form of deep endometriosis, see later discussion); endometriosis over a vital organ such as the bladder, bowel, or ureter; a patch of endometriosis or an area of peritoneum after adhesiolysis; a retraction pocket of peritoneum often caused by endometriosis. It is sometimes difficult to know when a superficial lesion involves deeper tissue, and excision has been advocated by some investigators for all cases of endometriosis.12,52
Fig. 1. Atypical and subtle phenotype of adolescent endometriosis as widespread brown lesions.
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Fig. 2. Atypical and subtle phenotype of adolescent endometriosis as widespread vesicular or miliary lesions.
Energy Sources
Energy sources that have been used (for excision or ablation) include monopolar scissors, “cold” scissors, ultrasonic energy (harmonic scalpel), and lasers (potassium titanyl phosphate or KTP, neodymium-doped yttrium aluminum garnet or Nd:YAG, carbon dioxide or CO2). The type of energy used is not as important as understanding the energy and being able to use the energy source to achieve optimal surgical treatment of the disease. For example, with monopolar energy, because the energy arcs from the tip of the instrument to the tissue (and then through the body to ground), the type of current and the presenting surface area (power density) of the instrument are important variables. It is recommended with monopolar energy (35–40 W and sometimes higher) to minimize the surface area of the presenting tip (using the utmost tip of the scissors) and to use cut current to increase cutting precision and reduce lateral thermal injury. With the free-beam CO2 laser, higher power (in the range of 12–15 W) can increase the precision of the laser as a cutting instrument, although one must be careful not to let the laser dwell in one place over vital structures. Safe practice, knowledge of the energy, and proper training are important for whichever energy source is used.
Fig. 3. The goal of endometriosis surgery is optimal excision of all visible lesions, both typical and atypical, with minimal char and good hemostasis.
Endometriosis in Patients with Pelvic Pain
Fig. 4. (A, B) The goal of surgery for endometriosis with an obliterated cul-de-sac is restoration of anatomy and excision of visible or deep disease.
Treating Endometriomas
Evidence supports cystectomy (removal of the entire cyst wall) over incision and drainage for the treatment of ovarian endometriomas or “chocolate cysts,” pain, recurrence, and fertility.53 In cases where a cycle-day 3 follicle-stimulating hormone levels and antimullerian hormone (AMH) levels suggest reduced ovarian reserve, patients should be given an opportunity to harvest ova for future use if desired. Cystectomy has not been shown to negatively affect controlled hyperstimulation results.54 Cystectomy has been shown to reduce AMH levels,55,56 although it would seem that good surgical technique in finding the true plane between the cyst wall and the normal ovarian tissue is important.57 In addition, it is unclear whether the presence of an untreated endometrioma is also associated with a similar decline in AMH.58 Overall, most fertility specialists (95%) would offer cystectomy for endometriomas in patients for whom IVF is not an option, or for larger endometriomas (>3 cm) for patients undergoing IVF.59 Other Techniques
Ureterolysis is an important technique that should be used when lesions are found over the ureter. Gynecologists who treat endometriosis should be familiar and comfortable with performing ureterolysis when appropriate. Ureterolysis involves freeing the ureter off the peritoneum, usually by sweeping parallel to the direction of the ureter on the medial side (Video 1). Bilateral ureterolysis is also an essential step when approaching an obliterated cul-de-sac. Exploration and dissection of the retroperitoneal space and ureterolysis are important techniques for any surgeon treating advanced endometriosis or deep disease. Knowledge of the retroperitoneal anatomy, the course of the ureter, and how to control bleeding by procedures such as hypogastric artery or uterine artery ligations will aid in excising deep pelvic endometriosis. Treatment of an obliterated cul-de-sac requires a systematic approach to restoring the anatomy and removing the disease, which usually involves cystectomy, bilateral ureterolysis, and a lateral to medial approach to release the bowel from the retrocervical or rectovaginal space. Vignali and colleagues48 showed that surgical completeness of removal of deep disease will affect the rate of recurrence of endometriosis. Preoperative Bowel Preparation
Preoperative bowel preparation has traditionally been used for diagnostic/operative laparoscopy for endometriosis, especially in cases when bowel endometriosis, deep endometriosis, or an obliterated cul-de-sac is suspected. Systematic reviews no longer recommend preoperative bowel preparation for gynecologic surgery, because
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it has not been shown to decrease the risk of bowel repair leakage or the need for colostomy.60,61 That said, it is important to discuss the use of preoperative bowel preparation with the colorectal or general surgeon participating in the patient’s care. Definitive Surgery
Many consider definitive surgery for endometriosis to be total hysterectomy and bilateral salpingo-oophorectomy. The reasoning is to remove the uterus and thus the risk of adenomyosis (and, because menstruation is often painful, even without a pathologic diagnosis of adenomyosis), and to cause a surgical menopause to remove the stimulation of endometriosis left in the pelvis. The problem with this approach is that the actual disease remains and can still cause symptoms (especially deep endometriosis), and the benefits of ovarian hormone production have been lost, including cardiovascular and bone health. Another surgical approach that should be considered, especially in younger women who have completed childbearing, is to optimally remove the endometriosis and the uterus (again to reduce the risk of adenomyosis) with the fallopian tubes (not needed without the uterus and to reduce the risk of ovarian cancer62), but to conserve at least one, or both, ovaries. Recurrence Rates
Recurrence rates of actual disease depend on the technique used, especially for deep endometriosis. Rates of recurrence (or persistence) of endometriosis after ablation are approximately 20% to 50% in 2 years63,64 (approaching 50% by 5 years65), but as low as 0% at 2 years after optimal excision.11 Of note, adding hormonal suppression after surgery does not further reduce the rate of actual recurrence of disease beyond the benefit of what is done at surgery, as noted by Doyle and colleagues20 (see earlier discussion). Recurrence of pain does not necessarily indicate recurrence or persistence of endometriosis. In particular, when optimal endometriosis surgery has been achieved, other causes of pain should be evaluated before repeat surgery. Recurrence rates after conservative surgery, even for advanced or deep disease, can be low (
MD
KEYWORDS Endometriosis Excision surgery Laser surgery Diagnostic imaging Pelvic pain Recurrence KEY POINTS Diagnostic laparoscopy is indicated for women whose quality of life is significantly affected, for whom hormonal suppression has failed (or is contraindicated), or who desire fertility. Transvaginal ultrasonographic imaging (which may include evaluation for deep endometriosis) can aid in surgical planning. Optimal excision or removal of disease is the best way to reduce recurrence rates, and may also be a way to conserve normal ovaries and avoid surgical menopause, even when hysterectomy or definitive therapy is indicated. Early diagnosis and treatment may be the best way to prevent the development of extensive disease and, perhaps, to preserve fertility.
Video of ureterolysis accompanies this article at http:// www.obgyn.theclinics.com/ INTRODUCTION
Endometriosis is estimated to be present in 1 of every 10 women.1,2 It is a condition whereby endometrial glands and stroma (normally found within the endometrial cavity and shed during the menstrual period) are found outside the uterine cavity. Endometriosis is an underdiagnosed and undertreated problem, and multiple studies have shown that it can take an average of up to 12 years to diagnose (especially in teenagers) from the time of onset of symptoms to the diagnosis at laparoscopy.3–6 This delay in diagnosis can contribute to impaired quality of life and may have implications for fertility.7–9 Center for Endometriosis, Division of Minimally Invasive Gynecologic Surgery, Department of Obstetrics, Gynecology & Women’s Health, Saint Louis University, 6420 Clayton Road, Suite 290, St Louis, MO 63117, USA E-mail address: [email protected] Obstet Gynecol Clin N Am 41 (2014) 371–383 http://dx.doi.org/10.1016/j.ogc.2014.05.002 obgyn.theclinics.com 0889-8545/14/$ – see front matter Ó 2014 Elsevier Inc. All rights reserved.
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Yeung Jr
Laparoscopy is the gold standard for the diagnosis of endometriosis, by visualization of implants characteristic of endometriosis or, better still, by histology of excised lesions.10 Laparoscopy is also the preferred route for treatment (when possible) of endometriosis because laparoscopy affords the benefits of magnification, illumination, and high-definition optics to better visualize the disease. Although there is no cure for endometriosis, optimal laparoscopic management can benefit patients with pain (and improve fertility) and improve their quality of life.11–13 Patients with endometriosis might benefit from early diagnosis and laparoscopic management, before progression of the disease, and providers should know when to operate and when to refer these patients.8 ENDOMETRIOSIS AND PAIN
Endometriosis is known to be associated with pain, and should be thought of as part of a comprehensive evaluation for pain.9 During the adolescent period at least 75% of patients who failed medical treatment were found to have endometriosis.7 Some algorithms recommend a diagnostic laparoscopy later in the evaluation after all other causes of pain have been ruled out or treated, including interstitial cystitis, vaginismus or myofascial pain, and pudendal neuralgia. Others recommend diagnostic laparoscopy sooner because endometriosis, unlike other causes of pain, can affect fertility, and surgical management for endometriosis may improve or preserve fertility.9,14 Although it is known that endometriosis and pain are associated, the exact causal relationship is not clear. Of note, the extent of disease (based on the most widely used revised American Society of Reproductive Medicine [r-ASRM] classification system15) does not correlate well with the severity of symptoms.16 The way that endometriosis is currently classified is based on extent of disease, the presence of endometriomas, and adnexal or cul-de-sac adhesions. Deep endometriosis (or deep infiltrating endometriosis [DIE]) is not a part of the current classification system. However, there is evidence to show that the location of deep endometriosis has some correlation to the location of pain,17 whereas the location of superficial endometriosis does not.18 Newer classification systems are being developed to include DIE.19 HORMONAL VERSUS SURGICAL MANAGEMENT
Hormonal suppression is often recommended as first-line treatment for pain thought to arise from endometriosis.10 Hormonal suppression can improve symptoms such as pelvic pain and dysmenorrhea. Empiric therapy with hormonal suppression, including a gonodotropin-releasing hormone agonist (GnRHa) or birth control pills, is often used to control symptoms, as a form of diagnostic trial, and to prevent progression of disease. However, a response to empiric therapy (meaning improvement in symptoms), for example, with a GnRHa, is not diagnostic for the presence of endometriosis.10 Failure of pain to respond adequately to hormonal suppression should be investigated further for endometriosis. Hormone suppression may do little to prevent recurrence or progression of the actual disease. A study of 90 patients by Doyle and colleagues20 in 2009 showed that hormonal suppression given after surgery worsened (10%) or did not change staging or extent of the disease (70%) in 4 of every 5 women. Moreover, studies have shown that the need for hormonal suppression to control pain in earlier years may be a marker for more advanced disease. Studies by Chapron and colleagues21–23 in 2011 showed that patients with severe endometriosis, when questioned about their adolescent history, had greater school absenteeism and an earlier or extended need for hormonal suppression to control pain in the adolescent years.
Endometriosis in Patients with Pelvic Pain
Finally, hormonal suppression does not improve fertility, neither while the patient is on suppression nor in the future.24,25 DIAGNOSIS History and Evaluation
Symptoms characteristic of endometriosis include the following: dysmenorrhea, chronic pelvic pain (more than 3 months of pelvic pain outside the menstrual period, between the umbilicus and the thighs), deep dyspareunia, period-related dyschezia, and period-related dysuria.10 Chronic pelvic pain has many different potential causes and is often multifactorial. Causes of chronic pelvic pain include endometriosis, pelvic inflammatory disease, interstitial cystitis, urinary tract infection, myofascial pain or vaginismus, and irritable bowel syndrome, to name a few.26 A thorough evaluation and testing of the causes of chronic pain should be performed as directed by the history. Moreover, chronic pelvic pain can lead to centralization or sensitization to pain, which may need to be addressed. Under such circumstances the brain is sensitized to feeling pain even when the source of pain is treated or diminished.27 A multimodal team approach is often the best way to treat chronic pelvic pain. Within the evaluation for chronic pelvic pain, endometriosis should be especially addressed if fertility or future fertility is desired.28 Indications for Laparoscopy
Providers who care for women should have a high index of suspicion for endometriosis when symptoms affect activities of daily living or quality of life. Examples include pelvic pain or dysmenorrhea that leads to absenteeism from school or work, deep dyspareunia that prohibits intercourse, or the need for narcotics to deal with pelvic pain.12 In the adolescent population in particular, patients who have chronic pelvic pain but whose symptoms fail to improve with hormonal suppression have a very high prevalence of endometriosis. Experts have recommended that expectant management is inappropriate in patients with a visual analog scale score of greater than 7 or in patients with a poor quality of life as subjectively assessed by the patient.29 Infertility is another reason to perform laparoscopy for endometriosis. Historically, all patients with infertility have received a routine laparoscopy for evaluation of endometriosis given the known association of endometriosis with infertility. Current recommendations for laparoscopy because of fertility concerns include: age younger than 30 years; when in vitro fertilization (IVF) is not an option; or when a patient has failed 2 attempts at IVF.28 The laparoscopic management of endometriosis has been shown to improve both pain30 and fertility outcomes.13,31 In a recent study by Lee and colleagues,32 42% of patients (with endometriosis ranging from stages I to IV) conceived successfully without hormonal treatment or artificial reproductive technologies within a year after surgery. In another study by Darai and colleagues33 in 2005, pregnancy rates for a cohort of 34 women requiring colorectal bowel resection for advanced disease was 45% within 24 months. The Potential Benefit of Early Diagnosis and Treatment of Endometriosis
Endometriosis is thought to be a progressive disease, although not in all cases.8,34 Thus extensive or deep disease can arise from superficial disease. Some have touted the benefits of diagnosing and treating endometriosis earlier in the disease process, even in adolescence, which could improve lifelong pain and quality of life, and reduce the rate of progression to more advanced disease.13 Early intervention and optimal removal of disease, by reducing the rate of recurrence or progression, has the
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potential to improve or preserve downstream fertility,12 although this has to be systematically studied. Preoperative Examination
The goal of surgery should be to “see and treat” laparoscopy when possible.35 That is, at laparoscopy the disease is fully identified and optimally treated at the same time. The best way to achieve this is with thorough preoperative planning that includes history, physical examination, and preoperative imaging, usually transvaginal ultrasonography (TVUS). A physical examination should include assessment of the uterosacral ligaments (thickening, shortening, nodularity), mobility of the uterus and adnexa, adnexal masses, and a rectovaginal examination for cul-de-sac nodularity. Deep disease may be able to be diagnosed or suspected preoperatively, and ideally managed at surgery in a multidisciplinary fashion if necessary.36 A history of dyschezia may increase suspicion for deep disease. A fixed or immobile uterus, or cul-de-sac nodularity, would imply an obliterated cul-de-sac or deep endometriosis. Preoperative Imaging
TVUS is the imaging modality of choice for the assessment of suspected endometriomas or deep endometriosis. TVUS is an excellent imaging modality for female reproductive organs, and can be performed in the gynecologist office setting, although it is fairly operator-dependent.10 With proper training and experience in specialized centers, TVUS with bowel preparation (TVUS-BP), whereby the distal bowel has been emptied by an enema, has been shown to be as accurate as pelvic magnetic resonance imaging in diagnosing deep endometriosis in the posterior cul-de-sac.37–40 Preoperative ultrasonography may indicate deep disease directly, or indirectly if an endometrioma larger than 8 cm or bilateral endometriomas are suspected.41,42 In 2010 Goncalves and colleagues,37 in a study involving 194 patients, showed the ability of TVUS-BP to predict the number of lesions in cases of deep endometriosis with a sensitivity and specificity of 97% and 100%, respectively (for a single bowel nodule), and with a positive predictive value (PPV) and negative predictive value (NPV) of 100% and 98%, respectively. Regarding the diagnosis of infiltration of the submucosal/ mucosal layer, TVUS-BP had a sensitivity of 83%, specificity 94%, PPV 77%, and NPV 96%. Clearly this type of accurate imaging would be invaluable in helping to define the surgical strategy. If the surgeon or center is not able to manage deep endometriosis suspected before surgery or discovered at the time of surgery, the patient should be referred to a surgeon or center that is able to manage deep or extensive endometriosis.13,43 SURGICAL TECHNIQUES
The goals of laparoscopic surgery for endometriosis are: optimal removal or treatment of all visible and deep disease; restoration and preservation of anatomy and function; and adhesion prevention.29 Pelvic pain and fertility can be improved with surgical intervention.30,31 Near-Contact Laparoscopy
For early or mild forms of endometriosis (r-ASRM Stage 1–2), optimal excision depends first on recognizing endometriosis in all of its forms.11 The most common way to diagnose endometriosis is to visualize typical implants that have a “powderburn” appearance. However, a histologic diagnosis is more accurate, especially when the lesions have a more atypical or subtle appearance. Atypical lesions include
Endometriosis in Patients with Pelvic Pain
“red flame” lesions, white fibrotic lesions, vesicular or miliary lesions, and retraction pockets (sometimes called Allen-Masterson pockets) (Figs. 1 and 2).44 Careful and systematic near-contact laparoscopy should be used to find all lesions suspicious for endometriosis (Fig. 3).44 Removal of Deep Disease
For more advanced (or deep) endometriosis (r-ASRM Stage 2–4), optimal excision depends on not just recognition of peritoneal or superficial disease, but on recognition of deep disease and restoration of anatomy.45 Surgery in these cases often includes bilateral ureterolysis, cystectomy, adhesiolysis, and enterolysis, and opening of an obliterated cul-de-sac or “frozen” pelvis. Of note, adhesions distort not just anatomy but also visualization of endometriosis, so adhesiolysis alone is insufficient to achieve an optimal surgical result. Once adhesions have been reduced, excision of the peritoneum or deep disease must occur for proper treatment of endometriosis (Fig. 4). It has been suggested that surgery for ovarian endometriosis alone is insufficient treatment.42,46 Evidence shows that treatment of deep endometriosis, including bowel endometriosis and ovarian endometriomas, has been shown to benefit both pain and pregnancy outcomes,13 with low recurrence rates.47,48 Some have recommended that centers of excellence be created to manage difficult or challenging cases of endometriosis.49 Excision Versus Ablation
There is an ongoing debate about the best surgical method to treat endometriosis. Published comparative studies50,51 do not account for surgical experience, nor of the presence of deep endometriosis. There are several surgical scenarios in which excision (removing the disease whereby a specimen is produced and sent to histology) is intuitively superior to ablation (destruction of the disease with energy without a specimen being produced). Such situations would include: deep endometriosis (whereby ablation would just treat the “tip of the iceberg”); ovarian endometriomas (which can be thought of as a form of deep endometriosis, see later discussion); endometriosis over a vital organ such as the bladder, bowel, or ureter; a patch of endometriosis or an area of peritoneum after adhesiolysis; a retraction pocket of peritoneum often caused by endometriosis. It is sometimes difficult to know when a superficial lesion involves deeper tissue, and excision has been advocated by some investigators for all cases of endometriosis.12,52
Fig. 1. Atypical and subtle phenotype of adolescent endometriosis as widespread brown lesions.
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Fig. 2. Atypical and subtle phenotype of adolescent endometriosis as widespread vesicular or miliary lesions.
Energy Sources
Energy sources that have been used (for excision or ablation) include monopolar scissors, “cold” scissors, ultrasonic energy (harmonic scalpel), and lasers (potassium titanyl phosphate or KTP, neodymium-doped yttrium aluminum garnet or Nd:YAG, carbon dioxide or CO2). The type of energy used is not as important as understanding the energy and being able to use the energy source to achieve optimal surgical treatment of the disease. For example, with monopolar energy, because the energy arcs from the tip of the instrument to the tissue (and then through the body to ground), the type of current and the presenting surface area (power density) of the instrument are important variables. It is recommended with monopolar energy (35–40 W and sometimes higher) to minimize the surface area of the presenting tip (using the utmost tip of the scissors) and to use cut current to increase cutting precision and reduce lateral thermal injury. With the free-beam CO2 laser, higher power (in the range of 12–15 W) can increase the precision of the laser as a cutting instrument, although one must be careful not to let the laser dwell in one place over vital structures. Safe practice, knowledge of the energy, and proper training are important for whichever energy source is used.
Fig. 3. The goal of endometriosis surgery is optimal excision of all visible lesions, both typical and atypical, with minimal char and good hemostasis.
Endometriosis in Patients with Pelvic Pain
Fig. 4. (A, B) The goal of surgery for endometriosis with an obliterated cul-de-sac is restoration of anatomy and excision of visible or deep disease.
Treating Endometriomas
Evidence supports cystectomy (removal of the entire cyst wall) over incision and drainage for the treatment of ovarian endometriomas or “chocolate cysts,” pain, recurrence, and fertility.53 In cases where a cycle-day 3 follicle-stimulating hormone levels and antimullerian hormone (AMH) levels suggest reduced ovarian reserve, patients should be given an opportunity to harvest ova for future use if desired. Cystectomy has not been shown to negatively affect controlled hyperstimulation results.54 Cystectomy has been shown to reduce AMH levels,55,56 although it would seem that good surgical technique in finding the true plane between the cyst wall and the normal ovarian tissue is important.57 In addition, it is unclear whether the presence of an untreated endometrioma is also associated with a similar decline in AMH.58 Overall, most fertility specialists (95%) would offer cystectomy for endometriomas in patients for whom IVF is not an option, or for larger endometriomas (>3 cm) for patients undergoing IVF.59 Other Techniques
Ureterolysis is an important technique that should be used when lesions are found over the ureter. Gynecologists who treat endometriosis should be familiar and comfortable with performing ureterolysis when appropriate. Ureterolysis involves freeing the ureter off the peritoneum, usually by sweeping parallel to the direction of the ureter on the medial side (Video 1). Bilateral ureterolysis is also an essential step when approaching an obliterated cul-de-sac. Exploration and dissection of the retroperitoneal space and ureterolysis are important techniques for any surgeon treating advanced endometriosis or deep disease. Knowledge of the retroperitoneal anatomy, the course of the ureter, and how to control bleeding by procedures such as hypogastric artery or uterine artery ligations will aid in excising deep pelvic endometriosis. Treatment of an obliterated cul-de-sac requires a systematic approach to restoring the anatomy and removing the disease, which usually involves cystectomy, bilateral ureterolysis, and a lateral to medial approach to release the bowel from the retrocervical or rectovaginal space. Vignali and colleagues48 showed that surgical completeness of removal of deep disease will affect the rate of recurrence of endometriosis. Preoperative Bowel Preparation
Preoperative bowel preparation has traditionally been used for diagnostic/operative laparoscopy for endometriosis, especially in cases when bowel endometriosis, deep endometriosis, or an obliterated cul-de-sac is suspected. Systematic reviews no longer recommend preoperative bowel preparation for gynecologic surgery, because
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it has not been shown to decrease the risk of bowel repair leakage or the need for colostomy.60,61 That said, it is important to discuss the use of preoperative bowel preparation with the colorectal or general surgeon participating in the patient’s care. Definitive Surgery
Many consider definitive surgery for endometriosis to be total hysterectomy and bilateral salpingo-oophorectomy. The reasoning is to remove the uterus and thus the risk of adenomyosis (and, because menstruation is often painful, even without a pathologic diagnosis of adenomyosis), and to cause a surgical menopause to remove the stimulation of endometriosis left in the pelvis. The problem with this approach is that the actual disease remains and can still cause symptoms (especially deep endometriosis), and the benefits of ovarian hormone production have been lost, including cardiovascular and bone health. Another surgical approach that should be considered, especially in younger women who have completed childbearing, is to optimally remove the endometriosis and the uterus (again to reduce the risk of adenomyosis) with the fallopian tubes (not needed without the uterus and to reduce the risk of ovarian cancer62), but to conserve at least one, or both, ovaries. Recurrence Rates
Recurrence rates of actual disease depend on the technique used, especially for deep endometriosis. Rates of recurrence (or persistence) of endometriosis after ablation are approximately 20% to 50% in 2 years63,64 (approaching 50% by 5 years65), but as low as 0% at 2 years after optimal excision.11 Of note, adding hormonal suppression after surgery does not further reduce the rate of actual recurrence of disease beyond the benefit of what is done at surgery, as noted by Doyle and colleagues20 (see earlier discussion). Recurrence of pain does not necessarily indicate recurrence or persistence of endometriosis. In particular, when optimal endometriosis surgery has been achieved, other causes of pain should be evaluated before repeat surgery. Recurrence rates after conservative surgery, even for advanced or deep disease, can be low (
